Burn Injury-High Acuity Flashcards
1
Q
Burn Injury
A
tissue injury caused by
- thermal
- electric
- chemical
- radiation
2
Q
Which 2 populations are at highest risk for burn injury?
A
- Children (less than 4yrs)
- Older adults (greater than 65 yrs)
3
Q
In children, which burn injuries are most common?
A
scald injury or abuse/neglect
4
Q
In older adults, which burn injuries are most common?
A
kitchen injury or smoking
5
Q
Pediatrics
A
- thin skin (increased severity)
- large surface/volume ratio (rapid fluid loss & increased heat loss)
- immature immunological response (sepsis risk)
- *Always consider possibility of child abuse
6
Q
Geriatrics
A
- thin skin (increased severity)
- decreased myocardial reserve (fluid resuscitation is difficult)
- PVD & Diabetes (slow healing and impaired senses)
- COPD (airway complications are increased)
- Poor immunological response (sepsis risk)
- higher risk for infection
- diminished microcirculation
7
Q
How to measure % mortality
A
Age + % BSA burned
8
Q
3 Layers of the skins
A
- Epidermis
- Dermis
- Hypodermis (subcutaneous)
9
Q
Epidermis
A
protective barrier (prevents infection)
10
Q
Dermis
A
cells that help create new ones (cell regeneration)
11
Q
Hypodermis (subcu)
A
tissue, veins, arteries, nerves (regulates body temp)
12
Q
Injuries to the skin increase the risk of:
A
- hypovolemia (cannot maintain water balance)
- hypothermia (cannot maintain temp)
- infection (protective barrier is lost)
13
Q
Thermal Burns
A
- dry heat
- moist heat
- smoke & inhalation injury
14
Q
Dry heat
A
- contact burn (hot stove)
- flame burn (fire)
15
Q
Moist heat
A
scald burn (hot water, oils)
16
Q
Inhalation severity depends on
A
- ignition source
- size and diameter of particles
- duration of exposure
- solubility of gases
17
Q
Complications of thermal injury
A
- burn edema
- fluid loss
18
Q
Burn edema
A
- increased vascular permeability
- leak of fluids and proteins into interstitial space (fluid shifts)
19
Q
Fluid loss
A
evaporation from burn wound
20
Q
Chemical Burns
A
Acid, base or organic
21
Q
Acid
A
not as severe; eschar prevents penetration into deeper tissues
22
Q
Alkali/base
A
more severe; protein liquefaction occurs and allows penetration into deeper tissues (more damage)
23
Q
Organic
A
can be absorbed systemically and lead to renal and liver damage
24
Q
Inhalation-chemical burns
A
Lung injury and systemic absorption can occur; leading to pulmonary, CV, renal and liver damage
25
Tx for chemical burn
- Get the chemical off
| - wash immediately (remove clothing, socks and shoes too)
26
Chemical burn--NEVER attempt to:
neutralize the chemical
| -can cause more burns from heat
27
Electrical
skin: best resistor
| nerves & BV: best conductor
28
2 types of Electrical
- Low voltage
| - High voltage
29
Low Voltage
Alternating or direct
30
Alternating current
produces tetanus muscle contractions
| **more severe
31
Direct current
hurls person away from current source
32
Currents--NEVER go near a patient until
current is off (could risk harming yourself)
33
High Voltage
Arc (flash burns or lightning)
34
S/S of electrical burns
- vision problems
- fractured bones
- entry and exit burn
- swollen tongue
- arrhythmias
- paralysis
- respiratory problems
- LOC
- twitching muscles or seizures
35
Management of electrical burns
- stop current first, then extinguish clothing fire
- ABC
- cardiac monitoring
**prolonged CPR is warranted
36
Management of electrical burns cont'd
monitor:
- ECG
- ultrasound of abdomen
- chest x-ray
- CT scan of head
- Cardiac enzyme analysis
- acidosis
- release of myoglobin (muscle damage)
37
Radiation burn
```
radiation therapy (damage to cells)
-background, industrial or lab accident
```
38
Radiation burn effects are evident in cells:
- skin
- blood vessels
- GI lining
- neurovascular syndrome
39
Radiation management
safety--protective equipment
| -need for decontamination
40
4 Phases of body response to burns
Emergent (1)
Fluid shift (2)
Hypermetabolic (3)
Resolution (4)
41
Emergent
- pain response
- catecholamine release
- tachycardia, tachypnea, hypertension, anxiety
42
Fluid shift
- 18-24 hrs
| - damaged cells initiate inflammatory response (massive edema)
43
Hypermetabolic
- days to weeks
| - large increase in the body's need for nutrients as it repairs
44
Resolution phase
- scar formation
| - rehabilitation and progression to normal function
45
1st 24 hours after injury
Ebb Phase occurs
46
Ebb phase goal
to conserve volume and energy for recovery and repair; this leads to hypofunction/hypovolemic shock
47
Hypofunction manifestations
- hypotension
- low CO
- metabolic acidosis
- hypoventilation
- hyperglycemia
48
Flow Phase (resuscitation)
gradual increase in:
- CO
- HR
- oxygen consumption
- increase in temp
49
Burn injuries effect:
- cardiovascular
- pulmonary
- renal
- nutrition
- GI
50
Cardiovascular
- decreased CO
- decreased volume (burn shock)
- decreased perfusion to organs and periphery
- ST & T changes (electrical)
- dysrhythmias
51
Pulmonary
- increased PVR, PAP, PAOP
- pulmonary edema
- decreased diffusion
- circumferential chest burns (eschar stiffness affects chest expansion)
- inhalation injury
52
Renal
Risk for Rhabdomyolysis/Myoglobinuria (reddish-brown urine indicative of muscle damage)
53
If myoglobin is present in the urine
- adequate UO of 0.5-1mL/kg/hr is needed to prevent renal failure (IV fluids)
- mannitol used to increase diuresis and promote clearance of myoglobin
- alkalize urine to prevent crystalization of tubules (obstruction) by giving Sodium bicarb 50mEq IV
54
Nutrition
- Enteral nutrition needs to be implemented within 24 hours after injury
- high calories, protein, glucose control
- enteral preferred (maintains GI motility)
55
Things to monitor with nutrition
-wound healing
-weight
-protein and prealbumin levels
(is it working?)
-enteral: residual & BM
56
GI
- Curling's ulcer (gastroduodenal injury from reduced perfusion but increased acid production)
- 1st 24 hours after burn (reduced GI bf and mucosal damage)
57
Curling's Ulcer tx
- PPI
- H2 blockers
- early enteral nutrition
- mucoprotectants
**monitor for sudden drop in hgb or heme positive stool
58
Depth of Burn injury depends on:
- source/type
- temperature
- duration of exposure
59
Burn classifications
- 1st degree (partial thickness)
- 2nd degree (superficial partial thickness or deep partial thickness
- 3rd degree (full thickness)
- 4th degree (full thickness)
60
1st degree (partial thickness)
- erythema (redness)
- no blisters
- heals without intervention (3-5 days by sloughing)
- no scarring
- painful
**Think sunburn
61
2nd degree (superficial partial thickness)
- pain
- blister
- moderate edema
- heals with re-epithelialization (10-14 days)
- no scarring
- potential for hypo/perpigmentation
62
2nd degree (deep partial thickness)
- red/white mottled skin
- significant edema
- pain or no pain
- heals with skin graft (2-3 weeks or more)
- potential scarring
63
3rd degree (full thickness)
- full skin destroyed
- white, leathery appearance
- muscle and bone may be destroyed
- painless
- no cap refill
- skin graft or flap
64
4th degree (full thickness)
- subdermal
- penetrates deep tissue, fat, muscle, bone
- charred and dry
- immediate professional tx (graft, amputation)
- no sensation
65
Wound conversion
progression of burn to a deeper injury
- increased depth of wound
- viable tissue may become non-viable
66
Wound conversion causes
due to:
- inadequate fluid resuscitation
- infection
- hypothermia
- external pressure
67
3 Burn zones
- coagulation (immediately nonviable)
- stasis (may become nonviable)
- hyperemia (viable)
68
Assessment of burns
- TBSA
| - used to determine fluid requirements and nutritional needs
69
3 Methods of burn assessment
- Wallace Rule of 9s
- Lund & Browder chart
- Rule of palms
70
Rule on Nines
add all of the percentages, based on their locations of injury
71
Lund & Browder chart
Adjusts TBSA for age; a child’s body is proportioned differently than an adult’s.
72
Rule of Palms
use of hand as a tool to measure burn surface areas which are < 15%
73
Indications for intubation (Airway)
- oropharyngeal erythema/swelling on direct visualization
- persistent cough, stridor, wheezing, or hoarseness
- deep facial or circumferential neck burns
- nares with inflammation or singed hair
- carbonaceous sputum or burnt matter in the mouth or nose
- blistering or edema of the oropharynx
- depressed mental status, including evidence of drug or alcohol use
- respiratory distress (dyspnea, tachypnea)
- hypoxia or hypercapnia
- elevated carbon monoxide and/or cyanide levels
74
Breathing Assessment
-Circumferential full thickness burns may impair ventilation (eschar is thick)
-Blast injuries can cause pneumothorax & lung contusions
-chemicals (plastic) can cause a chemical pneumonitis & cyanide poisoning
-Carbon monoxide poisoning
(if COHb > 15 – 40% ventilate)
75
Upper airway inhalation injury
- supraglottic
- inhalation of hot air
- upper airway edema peaks at 24-48 hrs
- singed hair, facial burn, stridor
**monitor for obstruction and administer O2 and elevate HOB
76
Lower airway inhalation injury
- infraglottic
- inhalation of toxic gas and chemicals
- injury to mucosa and cilia (leads to tracheobronchitis)
* *may present w/o symptoms at first
- then cough, hypoxemia, chest tightness, adventitious lung sounds
77
Early tx of inhalation injury
- focused resp assessment
- humidified oxygen
- ET tube intubation
- pulmonary hygeine (TCDB, IS)
- monitor ABGs, CXR, bronchoscopy
78
Cyanide poisoning
- from plastic
- prevents O2 release from blood to tissues (anaerobic metabolism occurs)
**increased lactate and anion gap
79
Carbon monoxide toxicity
Carbon monoxide binds with Hgb
-SaO2 and SpO2 will be falsely high (give oxygen, monitor COhgb levels)
80
Interventions for burns
- circulation
| - fluid resuscitation
81
Circulation
- monitor BP, HR, color of unburnt skin (baseline)
- 2 large bore IVs
- doppler exam of burnt extremities
82
Fluid Resuscitation
* **critical to prevent burn shock
| - maintain organ perfusion (MAP >90)
83
Parkland formula (fluid resuscitation) 24 hour
4mL of LR x % TBSA x kg
give half over the first 8 hours, remainder over 16 hours
84
Fluid-monitor:
- Hgb & Hct
- urine osmolality
- serum electrolytes
- creatinine and BUN
- CVP
- Arterial BP
85
Criteria for Burn unit transfer
- greater than 10% TBSA
- burns that involve the face, hands, feet, genitalia, perineum, or major joints
- third degree (full thickness) burns in any age group
- electrical burns, including lightning injury
- chemical burns
- inhalation injury
- burn injury in patients with preexisting medical conditions
- burns with trauma
- children
86
Escharotomy for burns:
incision through eschar to expose fatty tissue below (circumferential burns)
87
Fasciotomy
For burn-induced compartment syndrome: within muscle compartment, incision to the fascia
(circumferential burns)
88
indications for escharotomy
```
cyanosis
pain
paresthesia
impaired capillary refill
decreased peripheral pulses
```
89
Wound care for burns
- ABC and stabilization first
- Stop burning process
- Cleanse wound - sterile saline
* *No ointment if being transferred
90
Types of debridement
- mechanical (irrigation)
- biosurgical (maggot debridement)
- chemical (enzymes)
- surgical (fascial or tangential excision)
91
signs of burn wound infection
- early separation of burn eschar
- color change
- increased exudate
- increased pain or depth
92
Tangential Excision
removal of thin slices of burned skin
-used for deep dermal burns and 3rd degree
**high risk for blood loss
93
Fascial Excision
removes all layers of eschar and underlying tissue to level of fascia
- if subcu fat is burned
- >60% FTB
94
FTSG
used for elbows, hands, and scapula
- not cosmetically appealing
- durable (less risk of contracture)
95
STSG
thinner
harvested with dermatome
meshed to cover larger area
more cosmetic
96
meshed grafts
- allows escape of subgraft fluid
| - increases size of available tissue
97
2 types of dressings
- open method
| - closed method
98
open
- silver sulfadazine
- no dressing
- common with face, head, neck burns
99
closed
- sooth and protect wound
- reduces pain
- absorbent
100
Steps to wound care
1-remove bandage
2-debridement
3-sterilization
4-reapply bandage
101
Rehabilitative phase
- pain control
- pruritis
- psychosocial needs
- physical mobility
- scar management
102
physical mobility
-early ambulation
103
Scar management
- compression garments
| - skin conditioning
